Mental Health Service Request Form

Mental Health Service Request Form

Please allow up to 72 hours for a member of our team to process your request. Filling out this request will put you on our rotation to see a provider. Provider availability may vary. Please note that this request does not put you into direct contact with a mental health provider. For immediate medical concerns please call 911. For mental health crisis intervention in Atlantic County, please call 609-344-1118.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Gender*
Phone Number*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Parent/Guardian (if client is under 18)

First NameLast Name
Payer Information*
Insurance Name*
Member ID#*
How did you hear about us?
Type of Services Requested*

Individual TherapyFamily TherapyCouples TherapyGroup TherapyPsychiatric Services/Medication MonitoringOther
Elaborate Reasons for Requesting Services:*

Availability for Session (Please mark all time frames you are available for sessions)*

Provider Demographic Preference (Gender, Race, Age etc)
*Disclaimer- More specific requests may result in a longer wait for for a provider*
Does Someone you know Obtain Services from us?

NoYes
Should be Empty: